Inspection on 14/01/08 for Beverley Lodge

This inspection was carried out on 14th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beverley Lodge 29/10/08

Beverley Lodge 16/11/06

Beverley Lodge 19/12/05

Beverley Lodge 28/09/05

Beverley Lodge 20/01/05

Beverley Lodge 14/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beverley Lodge 122 Grove Road Sutton Surrey SM1 2DD Lead Inspector Mohammad Peerbux Key Unannounced Inspection 14th January 2008 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beverley Lodge Address 122 Grove Road Sutton Surrey SM1 2DD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8643 4128 020 8643 0673 zeenatnanji@aol.com Mr Nanji Zeenat Nanji Mrs Doreen Margaret Hynes Care Home 19 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (19) of places Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 19) Dementia - Code DE (of the following age range: 65 years and over) (maximum number of places: 8) The maximum number of service users who can be accommodated is: 19 16th November 2006 2. Date of last inspection Brief Description of the Service: Beverley Lodge is a residential care home for older people providing nursing care. The home is close to local amenities and public transport systems. Beverly Lodge is a large, detached, domestic style house. The home has a single large lounge, which is also used as a dining area. This area was extended previously. The home has the usual facilities including toilets, bathrooms/ showers, laundry, sluice, kitchen and office. There is also a lift. There is large garden to the rear and off street parking facilities to the front. The garden can be accessed by wheelchair users via a ramp. The home is well maintained and has a friendly atmosphere. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first announced inspection for the year 2007/2008.This inspection was facilitated by the registered manager and registered provider. Various records were looked at as well as staff files for the three care workers employed. All registered adult services are now required to to fill in an annual quality assurance assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some of the residents were spoken and they commented positively on the care they were receiving. One resident stated, “Staff are very helpful, they do their best”. Another resident stated, “ They look after me very well”. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. There has been concern raised by one relative as far as Safeguarding Adult is concerned and the Local Authority is carrying out an investigation at present. What the service does well: Comments from residents were generally positive, with indication that staff are kind and helpful in meeting their care needs. They were observed to be treated with respect by staff and to have their privacy and dignity respected. The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet residents’ needs. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home has a training plan and intends to train its staff in health care to achieve accreditation. The home’s recruitment procedures protect the residents through vigorous staff vetting. The home is pleasantly designed and furnished, providing communal living, recreational and dining space that meets individual and collective needs. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. EVIDENCE: Three residents’ files were sampled at random and evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home. However the manager is reminded that the needs assessment must be completed in full so that staff are aware of the residents’ needs and how to meet them. Intermediate care for rehabilitation and return to the community is not provided by this home. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are not being appropriately met as their care plans are not being reviewed and updated to reflect their changing needs and the care plans do not always cover all their care needs. The system for administration of medications is not always consistent and could potentially place residents at risk. EVIDENCE: Five residents’ care plans were sampled at random and it was noted they generally included information necessary to deliver the resident’s care but did not cover all the residents’ needs. For example two of residents suffer from diabetes, these were not covered in their care plans. Another resident suffers from Parkinson and dementia again these care needs were not covered in his care plan. This was discussed in depth with the manager. Residents’ care plans Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 10 must include all aspects of their health, personal and social care needs to ensure that all their needs are met. There is a key worker system that allows staff to work on a one to one basis and contribute to the care plan for the individual. Some care plans, which were sampled, were not being reviewed and updated on a monthly basis. For example one resident has seven care needs identified on his care plan. On his last care plans review there was only “keeping well” written as part of the review. This does not reflect the care needs of the resident. This was again discussed in depth with the registered manager and provider. The home must ensure that residents’ plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Records show that the home arranges for health professionals to visit residents in the home and provides facilities to carry out treatment. The manager stated that none of the residents have pressure sores. The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but signed or not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The administration/non-administration of all medication must be recorded accurately at all times for the health and safety of residents. It was noted that there was no record of the receipt of antibiotics for one resident. Records must be kept of all medicines received by the home to ensure that there is no mishandling. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. One resident stated, “Staff are very helpful, they do their best”. Another resident stated, “ They look after me very well”. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social and cultural needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. Religious needs are met through a 2 monthly church service for all residents. There is also a fortnightly visit from the Catholic Church to give communion. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 12 The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. It is clear that the home encourages individuals and groups from the community to visit the home. The home holds regular meetings every 3 months with the residents, where relatives and friends are also invited. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. The home has purchased a computer for the residents so that they can have internet access.A new plasma television has also been installed to enhance the viewing experience for the residents. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The menu is incorporated to reflect ethnic minority residents’ choices. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. Most of the staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. Presently there is an investigation being carried out by the Local Authority in the care of one resident who used to live at the home. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet residents’ individual and collective needs in a comfortable and homely way. Residents’ bedroom are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 15 The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. The home’s recruitment procedures protect the residents through vigorous staff vetting. EVIDENCE: Resident spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Generally residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Three staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 17 The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The manager is aware that there are some gaps in the training programme. These are being addressed and further training sessions have been arranged. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally managed well. There is a good equality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: The registered manager has the required experience to run the home. She is aware of and work to the basic processes set out in the NMS.There is a strong ethos of being open and transparent in all areas of running of the home. She is also aware of current developments both nationally and by CSCI and plans the service accordingly. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 19 Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The registered manager informed that small amounts of money are kept in separate envelopes for each resident with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. From staff files sampled at random there were evidence that generally staff are being supervised on a regular basis. Records with regards to health and safety are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. Fire drills are being carried out at least four times a year in line with a requirement made at the last inspection. Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Residents’ care plans must include all aspects of their health, personal and social care needs to ensure that all their needs are met. The home must ensure that residents’ plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. The administration/nonadministration of all medication must be recorded accurately at all times for the health and safety of residents. Records must be kept of all medicines received by the home to ensure that there is no mishandling. Timescale for action 15/03/08 2. OP7 15(2) 15/03/08 3. OP9 13(2) 15/01/08 4. OP9 13(2) 15/01/08 Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beverley Lodge DS0000019077.V358283.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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